Chronic diseases of lifestyle curriculum: Students’ perceptions in primary health care settings

Background Community-based primary health care (PHC) forms the foundation of healthcare in South Africa. Medical programmes need to equip future health practitioners to face the challenges of the rising burden of chronic diseases of lifestyle (CDL) in different communities. Community-based education (CBE) contributes to developing knowledge, skills and attitudes appropriate to the challenges experienced in the PHC context. Aim To explore medical students’ perceptions of the current CDL curriculum and related programmes during CBE rotations. Setting The study was conducted among fourth- and fifth-year medical students at the University of the Free State, South Africa. Methods Focus group discussions were conducted and data were analysed thematically. Results Themes included perceptions of the CDL curriculum, relevance thereof for the PHC setting and barriers and challenges to implementing PHC programmes. This study identified foundational CDL content that needs to be incorporated or revisited at strategic points. Participants identified the need to contextualise educational programmes and focus on affordable, culturally acceptable and holistic healthcare prevention strategies. Barriers and challenges included high patient load, resource constraints, the lack of continuous care and focus on communicable diseases. Community-based education rotations were described as meaningful opportunities to develop professional attributes, competencies and skills. Conclusion This study identified foundational concepts to consider at key points throughout the curriculum. Incorporating creative and reflective learning activities in CDL modules can prepare students for the realities of PHC settings. Contribution This study provides insight into medical students’ perceptions of the CDL curriculum and informs future curriculum content for CDL modules.


Introduction
According to the World Health Organization (WHO), noncommunicable diseases are the leading cause of death globally. The projected increase in total deaths because of chronic diseases, from 36 million in 2018 to 55 million globally by 2030, will place a significant burden on healthcare systems, especially in developing countries. 1,2 Chronic diseases constitute an essential part of the overall disease burden in South Africa, accounting for 51% of total deaths. 3 Factors contributing to the growing tide of chronic diseases include epidemiologic transition (urbanisation), nutrition transition and socio-economic, cultural and behavioural or lifestyle-related risk factors. 4,5,6 Modifiable lifestyle changes include adaptation to a more Westernised diet, physical inactivity, increased alcohol intake and smoking. These behavioural factors can lead to physiological and metabolic adaptations and the development of chronic diseases of lifestyle (CDL). 1,7,8 reducing chronic diseases, improving the population's health and well-being and strengthening the country's health systems. 10 The Strategic Plan for the Prevention and Control of Non-Communicable Diseases states the importance of strengthening community-based primary health care (PHC) and focusing on, inter alia, social and economic determinants of health, unhealthy lifestyles and metabolic risks to prevent chronic disease. 11 Although some success in preventing and controlling chronic diseases has been reported, efforts to strengthen communitylevel prevention and control of chronic diseases in South Africa still need improvement. 12 Barriers and challenges reported in PHC settings in South Africa range from complex health and nutrition transitions, shortage of healthcare workers, inadequate training of staff in the comprehensive care approach for chronic diseases, the lack of supervision, the lack of patient knowledge, awareness and selfmanagement of chronic diseases. 13,14,15 In response to the government's commitment to improve the health profile of all South Africans and align with the health needs of local communities, 11 South African universities introduced community-oriented educational approaches to PHC into their curricula. Since 2014, community-based education (CBE) has been incorporated into several modules throughout the 5-year medical curriculum offered at the University of the Free State (UFS). Furthermore, a CBE and Interprofessional Education (CBE-IPE) platform was established in the rural Free State town of Trompsburg in 2016. Since 2020, a structured CBE longitudinal approach was phased in to link student community projects in different modules and consolidate vertical integration in the curriculum.
Barss et al. 16 emphasised the importance of evaluating the appropriateness of CDL curricula to ensure local and national future health practitioners are equipped to face national health priorities. Furthermore, the Health Professions Council of South Africa (HPCSA) encourages communitybased research to advance healthcare development, inform teaching and learning practices in the undergraduate curriculum and assist in delivering health practitioners who can provide healthcare in context. 17 The objectives of this study were to evaluate students' perception of the current CDL curriculum and explore experiences related to CDL programmes during CBE rotations in PHC settings in the Free State.

Study design
This study followed a descriptive exploratory qualitative design to provide an in-depth understanding of medical students' perceptions and experiences of the implementation of current CDL intervention programmes in Free State rural and urban settings.
Theoretical CDL knowledge is incorporated in foundational (semesters 1-3) and system-based modules (semesters 4 and 5) offered in the preclinical phase and in the Internal Medicine and Family Medicine modules presented in the clinical phase of the programme. 18 To apply theoretical knowledge in practice, a structured CBE longitudinal approach at various service-learning platforms of the FoHS was implemented in 2020. For example, students in the preclinical phase are exposed to the community and levels of healthcare in four modules presented in this phase. In the clinical phase, CBE rotations form part of the Family Medicine module. Fourthyear students (semesters 7 and 8) rotate in the rural town of Trompsburg in the Xhariep District and at primary health care facilities in the Botshabelo district during CBE-IPE training.
Fifth-year students (semesters 9 and 10) complete CBE rotation in the urban Mangaung District at the University Community Partnership Programme (MUCPP) clinic.

Study population and sampling strategy
The target population included all registered fourth-and fifth-year undergraduate medical students at the FoHs, UFS. The study sample comprised two groups. The first group was fourth-year medical students who had completed the required CBE rotation in the rural town of Trompsburg, and the second group was fifth-year students who had completed CBE rotation in the urban Mangaung district.
Focus group discussions were deemed an effective qualitative data-gathering method to present different perspectives and experiences and explore issues of concern. 19 The aim was to recruit 8-12 participants per focus group. Brink et al. 20 and Stalmeijer et al. 21 suggest an optimal number of 8-10 participants, with a maximum of 12-15 participants per focus group.
This study followed a purposive sampling technique to recruit students with relevant CDL knowledge gained through theoretical sessions attended and experience gained during scheduled CBE rotations in order to provide their perspective and insight concerning the research topic. 22 The study was done in the second semester of the academic year.
Recruitment included the electronic distribution of information letters (via class representatives) to all registered fourth and fifth-year students who had completed rotations in PHC areas. The information letter included the study's purpose, inclusion criteria, what was expected during the focus group discussions and the voluntary nature of the study. 23 Following a 3-week recruitment period, 22 students responded and the researcher scheduled an information session with the prospective participants. During this session, study information was verbally communicated, and participants had the opportunity to raise questions. After the researcher explained the voluntary nature of participation in the study (participants could withdraw at any time), written consent was obtained. 22 All participants who gave written informed consent and fulfilled all the inclusion criteria were included in the study. The researcher used the inclusion criteria to ensure a heterogeneous sample including participants from both genders, different ethnicities and varied social backgrounds.

Data collection
Focus group discussions were conducted in a seminar room in the Clinical Simulation and Skills Unit, FoHS. A set of questions was developed to guide the focus group discussions (Table 1). A senior member of the faculty who has a PhD degree in Health Sciences Education and experience as a facilitator for focus group discussions and nominal groups conducted the focus group discussions in English (the language of instruction). He is involved in the CBE-IPE training programme presented in the fourth year of the clinical phase of the medical programme. Focus group discussions lasted between 60 and 90 min. The facilitator followed an agenda compiled by the researcher that included an outline of the study purpose and a discussion of ground rules, confidentiality and respect for privacy before starting each focus group discussion. Each participant's assigned number (identifier) was displayed on a tag, and a seating chart was used for notetaking purposes. 22 The focus group discussions were recorded with a digital recorder, while the principal investigator observed the sessions. Documenting focus group discussions comprised MP3 audiotape recordings and written field notes taken by the principal investigator. Immediately after each focus group discussion, the principal investigator conducted a debriefing session with the facilitator to note important nonverbal communication, group dynamics, the effectiveness of questions and new topics that emerged during the discussion. 22 Because of the clear themes that emerged from the narratives as well as the saturation of themes, the researchers decided that the two focus group discussions held were sufficient for this exploratory study. 24,25

Data analysis
The principal investigator transcribed the recorded audio data verbatim and made field notes on the transcript, before listening to the audio recordings again and rereading the transcript to confirm accuracy. 23 Following an inductive strategy, the thematic analysis included data coding, identifying categories and subcategories and recognising emerging themes using Microsoft Office software (e.g. Microsoft Word and Excel) (Microsoft Corporation, Redmond, Washington, United States). 21 A systematic approach, adapted from Braun and Clark, 26 was followed to organise and interpret the qualitative data. The principal investigator first read through the transcript to obtain a general overview of the data. Statements relevant to the research topic and information not related to the research topic were separated (step 1). The researcher again reviewed the transcript notes, breaking the data into words, phrases and sections of text that reflected the participants' specific thoughts. The relevant text was highlighted in a unique colour to correspond with each code represented (step 2). The researcher then identified recurring codes (categories) for individuals, within a group and among different focus groups. The categories were grouped into themes and subthemes (step 3). After step 3 was completed, the main supervisor (co-author), an expert in qualitative research approaches, and the co-supervisor (co-author), both senior faculty members, moderated the processes independently by reviewing and comparing the codes and identified themes and subthemes against the dataset to ensure the credibility of the process (step 4). The authors then discussed, amended and finalised the themes and subthemes. The agreed-upon themes were then connected to develop descriptive or overarching themes that relate specifically to CDL and CDL intervention programmes as seen through the participants' eyes (step 5). 24,25 Credibility, transferability, dependability and confirmability were used as criteria to ensure the trustworthiness of this study. 20 Credibility was ensured by using the most appropriate methods for data collection and recruiting medical students who had relevant experience implementing CDL intervention programmes. The coauthors moderated the thematic exploration to ensure completeness and validity of the results. This was to confirm that categories and themes covered the data and that relevant data had not been accidentally excluded or irrelevant data included. 20,27 The principal investigator used a 'thick', detailed description of the study context to enable other researchers to conduct a similar study in other settings. 27 Dependability was assured by an audit trail, including detailed documentation of the chronology of the methodological and data analysis process through which the findings were derived. Reflexivity was ensured by recognising and limiting the researcher's bias because of background or past experience. The researcher is a healthcare professional involved in the training of medical students in the preclinical years and a coordinator for the second and third academic year of the medical programme; moreover, the researcher is also involved in the curriculum review and renewal processes. This was done by intentionally excluding preconceived ideas and subjective opinion through reflective thinking and adhering to stringent ethical processes. 21,28 Furthermore, after the researcher completed the systematic process to organise and explore associations between themes, the internal consistency of the interpretation of data and thematic saturation were confirmed by the other two authors.

Ethical considerations
Ethics approval was obtained from the Health Sciences Research Ethics Committee of the UFS (UFS-HSD2017/1435), the Free State Department of Health and local municipalities. The principal investigator (with the translator's assistance) explained the voluntary nature of the study before obtaining written informed consent from all participants.

Results
A total of 22 participants (18 women and 4 men) participated in focus group discussions; 12 fourth-year MBChB students and 10 fifth-year MBChB students. Table 2 provides an overview of the overarching themes and concepts, main themes and subthemes that emerged during the analysis. The discussions about the five main themes and associated subthemes are followed by quotes reflecting the students' perceptions and experiences.  The HPCSA 17 refers to core competencies that should be developed during the training of undergraduate medical students. For example, graduates must develop a range of competencies and essential skills relevant to the PHC setting. Participants indicated that CBE and IPE provided the opportunity to develop communication and collaboration skills and the different roles expected of a healthcare provider (e.g. being a health promoter and health advocate). Regarding collaboration and delivering integrated, holistic care, participants believed that earlier exposure (e.g. receiving lectures from the multidisciplinary team members from the first year in the preclinical years before CBE rotation) would be more beneficial: 'I don't feel that we are adequately trained, specifically regarding dietetics and when to refer accordingly.' The WHO 1 emphasised the importance of considering social determinants of CDL throughout the patients' lives. Participants reported that CBE provided them with an opportunity to observe the social, cultural and economic contexts of health and disease in communities and the role that they, as future physicians, and the patient (self-care), can play: '

Discussion
This study confirmed that CBE is a valuable experience in medical students' teaching and learning process. The students emphasised the importance of contextualising educational programmes in these communities and focusing on affordable, culturally acceptable and holistic healthcare strategies for CDL. Furthermore, this study identified foundational CDL content that needs to be incorporated or revisited at strategic points throughout the curriculum. Students identified specific challenges to the effective implementation of CDL programmes in urban and rural PHC settings. These challenges are not unique, as other African countries are experiencing similar challenges, 29,30 but such challenges should not be ignored. Research on students' experiences is necessary as the observations during CBE rotations can inform teaching and learning practices.
The integrated curriculum provides an important way to close the gap between theory and practice by reinforcing and integrating basic and clinical sciences. 31 Challenges often experienced in integrated curricula include making meaningful connections between the theoretical and applied content and ensuring a smooth transition from theory to practice. 32 In this study, participants identified such challenges by highlighting a need to revisit CDL protocols, prevention and intervention programmes before CBE rotation in the clinical phase commences. Participants also identified a disconnect regarding implementation of management protocols, where references were often made to CDL management as applicable for a tertiary or private healthcare setting and not what transpired in PHC settings. Gouda et al. 33 commented on the importance of incorporating preventive and lifestyle interventions in CDL curricula to equip students for PHC settings. Refresher courses in the clinical phase, before CBE-IPE rotations commence, can ensure a smooth transition from theory to practice and equip students for the realities faced in PHC settings. These courses should focus on preventive lifestyle interventions and treatment management protocols (e.g. essential drugs available in the public sector), roles and responsibilities of the PHC team and referral pathways). Reporting on global progress, the Commission on the Social Determinants of Health 34 emphasised the commitment and efforts of many countries at the national and local levels to improve the social determinants of health, quality and effectiveness of medical care. Although South Africa's National Health Promotion Policy and Strategy (2015-2019) 35 focuses on creating an enabling environment and strengthening human resource capacity to deliver health promotion services, there are still challenges and barriers to CDL health promotion and intervention strategies. Parker et al. 36 identified a lack of resources (including staff and equipment), high patient load and noncompliance as challenges and barriers experienced at PHC level for the effective implementation of CDL programmes. Participants in this study also observed staff shortages (urban and rural setting) and resource constrains (rural setting) and the high patient load (especially in the urban setting). Additionally, participants in the current study reported the lack of continuous care (incomplete files, different physicians in the rural setting), interventions not relevant for the socio-economic context (urban and rural setting), late presentation because of inadequate risk prevention measures (in the rural setting), cultural and traditional beliefs and greater emphasis on infectious diseases (HIV, TB). The latter was also observed in another South African community-based study. Madela et al. 37 commented on the strong emphasis on communicable diseases at the PHC level while observing deficiencies in CDL education, care and management. Furthermore, participants in the current study reported the lack of patient education, outdated educational material, posters that focus mainly on communicable diseases and health education that is not delivered in context (urban and rural setting). Chen et al. 38 suggested that intervention strategies should include the design of culturally sensitive programmes and educational materials to improve patients' knowledge and self-management.
Health empowerment focuses on strengthening the roles of individuals or communities to manage their own health by adopting healthier habits and providing health education and support to manage their disease. 39 Participants in this study reported that the focus in the primary setting remains mainly on treatment regimens and not preventive measures.
However, in the current study, some successful health empowering practices in the rural setting included fruitful health dialogue, support for hypertension and diabetes patients in lifestyle groups and a point reward system to enhance patient compliance. Sheik et al. 40  Participants in this study referred to the critical role that students can play in patient education and related selfmanagement and self-care. Health empowerment provides opportunities and skills to enable individuals or communities to take control of their own health needs. 39 In a collective effort between higher education institutes and the Department of Health in Ireland, an undergraduate chronic disease curriculum was developed that incorporated content on patient self-management and self-care. This assisted the students as future healthcare practitioners in developing competencies and skills to advise patients on self-management and assist patients in becoming actively involved in their own healthcare. 43

Study limitations
This study was conducted at only one higher education institution in South Africa, which included only two servicelearning sites -one urban and one rural -because of resource constraints. Furthermore, the study was conducted in one province in South Africa and represents specific challenges experienced within the particular province in an urban and rural PHC context. The researchers also acknowledge the small sample size. However, as a quality criterion in qualitative research, the transferability of the findings to different settings is enhanced through a thick description of findings in context and resonating with available literature in various settings. 44

Recommendations
The findings of this study led to the following recommendations regarding learning in CDL modules.
The CDL learning modules in the medical curriculum must provide creative learning opportunities for students to enhance their contextual understanding of the multifactorial aetiology that drives the CDL disease processes in communities. Incorporating reflective activities as part of a student professional development e-portfolio throughout the curriculum can enhance students' sociocultural and selfawareness. Furthermore, students can be involved in developing healthy lifestyle and health empowerment information or educational material during the CBE component of the CDL curriculum. The early exposure to interprofessional teaching and learning in the preclinical years of study is advised, as it can enhance the students' understanding of the role that different health professionals play in the holistic care of patients with CDL. Additionally, a treatment management refresher course before the CBE-IPE rotations focusing on the core knowledge applicable to the PHC setting can add value, for example, a course on the use of the WHO's 'package of essential non-communicable (PEN) disease interventions for primary health care' (p. 67). 45 Because CDL is not unique to the Free State, it is also advised that a national curriculum for CDL be developed through a collaborative effort between educationalists and policymakers, to produce healthcare professionals sensitive to the health needs, physical, mental and social well-being of communities, which can ultimately contribute to a healthy life for all.

Conclusion
The escalating burden of CDL in rural and urban communities in South Africa necessitates the need for effective communitybased health promotion and care. Community-based education should allow students to apply academic knowledge in context and observe the challenges faced during the implementation of CDL programmes in resourceconstrained PHC settings. Participants in this study identified specific challenges in the curriculum with particular reference to CDL content and identified important foundational knowledge that needs to be incorporated or revisited at strategic points throughout the curriculum. Although CBE provided a valuable opportunity to develop the student's knowledge, skills and attitude, this study revealed that more emphasis should be placed on the students' understanding of the biopsychosocial determinants of CDL and the development of self-efficiency (knowledge and confidence) to prepare future physicians for the realities of rural and urban PHC settings.